Atul Gawande: The Road Ahead

Before President Obama’s speech on health care, I wrote out a list of what I thought we needed him to do.

Make clear the stakes.

Make clear what we get under his reform.

Understand our fears.

Convey strength in the face of them.

Speak to our core beliefs as a nation.

I thought he did this and did it amply. He made clear that our present system is damaging our people and damaging our economy. He made clear that if we accepted the challenge and the struggle, we could have better insurance coverage without preëxisting condition exclusions or sudden disappearance of benefits. Those of us who are self-employed or unable to get coverage through work could have the kinds of insurance choices and discounts that big companies and congressmen can get. Those who don’t have the money for this coverage could get tax credits to offset the costs. The elderly would get a better drug-benefit package.

There was nothing here that was watered down or unfamiliar, either. He did not skirt the realities that this would have to be paid for—that government would be requiring many businesses to cover their employees and most individuals to carry insurance coverage, and that he would be using money from ending subsidies to Medicare HMOs to help finance the bill. And he spoke with podium-pounding conviction in response to the absurd charges that this would involve government takeover of our doctors’ offices and to the deeper fears that those charges fed into.

After far too many weeks, he again became the Barack Obama one could rally behind—the cool-headed president willing to face long odds and enemy fire, rather than the coolly calculating professor with the academic’s annoying certitude.

As I said, he checked all the boxes on my list. And yet I remain concerned that he may not have done enough.

The stone faces of his conservative enemies made clear the limits of what words could do. I was struck that for nearly the entirety of his speech, he spoke facing not the camera or the Democrats but the Republican throng. This debate has become a test of whom we will trust. Are we going to trust the Republicans, with their predictions of dark disasters that will result from going along with a President they do not believe should be allowed even to speak to our schoolchildren? Or are we going to trust this still new and untested President enough to give his changes a chance?

Obama has continued to defend policies that would push us, for the first time in history, in the direction of encouraging doctors to make more rational, better coördinated, less costly clinical decisions. This includes experiments with changing the way doctors are paid, a clinician board to identify inappropriate care, and a “fee” (i.e., tax) on extremely high-cost insurance premiums. I was also made hopeful by his willingness to break with Democrats and admit that the medical malpractice system is itself broken and, although not the cause of our cost crisis, a wasteful contributor.

But this is just a start. Our current health-care system—bloated, Byzantine, and slowly bursting—presents seemingly insurmountable difficulties. It is too big, too complex, too entrenched. What may be most challenging about reforming it is that it cannot be fixed in one fell swoop of radical surgery. The repair is going to be a process, not a one-time event. The proposals Obama offers, and that Congress is slowly chewing over, would provide a dramatic increase in security for the average American. But they will only begin the journey toward transforming our system to provide safer, better, less wasteful care. We do not yet know with conviction all the steps that will rein in costs while keeping care safe. So, even if these initial reforms pass, we have to be prepared to come back every year or two to take another few hard and fiercely battled steps forward.

In this way, successful reform will have to be more like a series of operations, with x-rays and tests in between to show how we’re doing. Embarking on the effort will be among the most severe challenges we take on as country. Outside the settings of war and economic collapse, we’ve never sustained any policy effort of this scope and duration. It is perfectly possible that our next push will be defeated, or used as an opportunity to dismantle the progress we’ve already made. But I can see no other choice. We can only forge ahead.

Atul Gawande, a surgeon and public-health researcher, became a New Yorker staff writer in 1998.